Heartburn Center Set-Up in a Community Setting: Engineering and Execution

Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a "center of excellence" (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD. Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery. Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1-11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution. Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.

[Results 2 to 5 years after implantation of the cement-free "APS" total knee prosthesis. A retrospective study of the first 160 cases]

One hundred-and-forty-seven out of 160 cementless APS total knees replacements have been clinically and radiologically evaluated with a mean follow-up period of 38 (24-60) months. Primary diagnosis has been osteoarthrosis in two thirds and rheumatoid arthritis in one. Reoperations have been performed in 4.9% due to aseptic loosening of the tibial tray, and in 3.7% due to patellar problems (aspetic loosening in 1.2% and luxation in 2.5%). There have been three late infections of the joint leading to arthrodesis in two or exchange operation in one case. The radiologic course of the remaining 126 implants showed excellent or good osseous integration of the implants in more than 80%. We were able to show that rheumatoid arthritis as well as malimplantation of the prosthesis can decrease the rate of osseous integration.

[Radiologic and sonographic screening study of shoulder joints of patients with rheumatoid arthritis]

In the course of a prospective study at our department the shoulder joints of 50 RA-patients were examined. Two criteria have been applied: only righthanded patients have been examined in order to ascertain any prevalence of changes in the dominant extremity, and only patients who were primarily admitted to our department because of complaints other than those of the shoulder. Examination consisted of anamnesis, clinical tests, radiography and sonography. Reports in the literature concerning involvement of 60%. This percentage was confirmed in our clinical and radiological examinations. If, however, sonography is used, it increases to 96%. Lesions of the rotator cuff can be demonstrated, beginning on the synovial side above bone erosions, without any clinical signs or radiographic changes. Radiographic changes have been rated according to Larsen stages 0-5. Upward migration of the humeral head already before massive bone destruction of the shoulder seems to confirm an early involvement of the rotator cuff. Involvement of the acromioclavicular joint begins with Larsen stage 2 and often includes a distension of the joint cavity. The dominant extremity was not found to be affected predominantly. The therapeutic consequences resulting from this examination are discussed.

Longterm analysis of Sheehan total knee arthroplasty

Sheehan total knee arthroplasty was carried out in 405 knees at two centres. The patients were followed up from two to eleven years. The clinical results were assessed, the complications documented and the influence of specific factors on the result was evaluated. The principal complications arose from the patella and the femorotibial articulation. The low rate of loosening and the achievement of satisfactory alignment lead the authors to support the concept of a long stem.

Long-term results after implantation of McKee-Farrar total hip prostheses

From 1973 to 1976, McKee-Farrar total hip arthroplasties were performed in the Orthopaedics Department at the Centre of Pulmology. In the present study, only patients with a complete record of radiological changes at the bone/implant or bone/cement interface were evaluated. A series of 81 patients with 100 total hip prostheses in situ according to the Mayo Clinic hip score and 36 patients who had undergone 36 revision operations were studied. The design of the metal cup with metal studs at the outer surface has a favourable effect on the stability of the implant/cement combination: loosening at the implant/cement interface did not occur in any of these cases and there were few cement fractures. In spite of the metal-to-metal combination, abrasion is slight and there is no danger of metallosis.

Collagenase synthesis of rheumatoid arthritis synoviocytes: dose-dependent stimulation by substance P and capsaicin

The synthesis and release of collagenase in the presence of the neuropeptide substance P (SP) and capsaicin, were investigated in vitro using identical synoviocyte cultures from patients with rheumatoid arthritis (RA). On average 10(-12) M SP augmented statistically significantly the collagenase production by approximately a factor of five. An increase in the concentrations up to 10(-6) M SP resulted in a decreased collagenase synthesis, which, however, was still above the level of that of the untreated synoviocytes. Capsaicin, a homovanillic acid derivative that acts as a releaser of SP from primary afferent neurons, caused a strong stimulation of collagenase production and release at 10(-8) and 10(-6) M (about 7 times the amount of the control). With increasing concentrations up to 10(-3) M capsaicin this effect diminished continuously. The experiments clearly show that in RA synoviocytes in vitro SP and capsaicin in low concentrations act as potent inducers of the synthesis and release of collagenase.

Effects of capsaicin on the metabolism of rheumatoid arthritis synoviocytes in vitro

The effects of capsaicin, the ingredient of hot pepper, on rheumatoid arthritis synoviocytes have been studied. Capsaicin was shown to have a direct action on the metabolism of synovial cells. Thus at 10(-6) mol/l and at higher doses DNA synthesis was restored to the control level. Capsaicin at both doses induced an increase in the synthesis of collagenase and at the lower concentration (10(-8) mol/l) only of prostaglandins. These results indicate that the different effects of capsaicin on cellular proliferation and on metabolic activities are dependent on dose. The responses seen in rheumatoid arthritis synoviocytes in vitro might not be mediated by tachykinins if the synovial tissue is still able to produce neuropeptides in the absence of neuronal afferents. These results suggest that capsaicin, in addition to its direct action on the afferent nervous fibres and the consequent release of tachykinins, may also have a direct action on the cells. The mechanisms by which capsaicin stimulates DNA synthesis and production of collagenase and prostaglandin E2, in a manner dependent on dose, remain to be determined.

[Intra-operative shaft fissure--a possible cause of postoperative shaft pain following cement-free hip joint implantation. 2d experimental study]

Two experimental studies carried out at the Institute of Pathology and Bacteriology, Baumgartner Höhe, Vienna, in cooperation with the Department of Orthopaedics of the Centre of Pulmology, City of Vienna, confirm the danger of intraoperative shaft fissures occurring during implantation of cementless hip endoprostheses. It appears that such lesions are not visible either during implantation or on postoperative radiographs. The study was made using the Zweymüller shaft system which is normally implanted at our department. Pain of unknown origin in the shaft area during the phase of patients mobilization may be connected with shaft fissures due to implantation.

Modulation of the migration and chemotaxis of PMN cells by hyaluronic acid

Hyaluronic acid (HA) has a dose-related inhibiting effect on the migration and chemotaxis of polymorphonuclear leucocytes (PMN) in vitro. These effects were measured with a new indirect quantitative assay. On average 1 mg HA/ml causes an inhibition to about 80% of the control (spontaneous migration). This effect increased progressively with an increasing HA concentration, and with 4 mg HA/ml only about 19% of the PMN were able to migrate in the in vitro system. Similar results were obtained in the presence of a potent chemotactic factor (leukotriene B4 [LTB4]). In the mean 1 ng LTB4/ml alone stimulated the chemotaxis of PMN by a factor of 3 compared to the spontaneous migration. The highest HA concentration (4 mg/ml) reduced the number of migrating PMN cells to about 17%. From these experiments it may be concluded that the HA in the synovial fluid of the healthy joint has a protective effect against the invasion of PMN cells. This functions is disturbed in inflamed joints by the decrease in the HA concentration and possibly by its depolymerization. The intraarticular application of high molecular weight HA might be an important therapeutic regimen to restore the natural barrier against PMN migration, also in the presence of chemotactic factors and could therefore be helpful for interrupting the inflammatory cascade.

Pressure-volume ratio in human cadaver hip joints

In postmortem examinations 26 hip joints of 23 adult individuals were filled with Ringer's solution in order to furnish data on the relationship between intra-articular pressure, capsular content, and joint position. A tube system was connected to an 18-gauge needle and to a pressure transducer. After instillation of 2.5, 5.0, 7.5, and 10.0 ml of Ringer's solution, intra-articular pressure was recorded in six different joint positions (extension, 45 degrees and 90 degrees flexion, 40 degrees internal and 40 degrees external rotation, and 45 degrees abduction in extension). Intra-articular pressure depends mainly on the position of the joint, with highest values in external and internal rotation and lowest values in 45 degrees flexion. In this last position, the pressure was zero in two of four cases after injection of 10 ml, whereas with external rotation and instillation of 2.5 ml almost 60 kPa was recorded. In extension and after filling with 10 ml the pressure exceeded the level of normal systolic blood pressure in all cases. Under pathologic conditions intra-articular pressure of the hip joint can rise well above arterial pressure and thus eventually compromise vascular supply to the femoral head, even in the presence of only minimal intra-articular effusion.

Shaft fissures due to implantation of cementless total endoprostheses of the hip joint. An experimental study

Since 1982, at the Orthopedic Department of the Pulmologic Center of the City of Vienna we have used the Zweymüller shaft system and the pyramidal threaded socket by Schwägerl when implanting cementless hip endoprostheses. Some patients repeatedly complained about pains in the shaft region within the first postoperative months, though these complaints could not be explained clinically or radiographically. On 15 human cadavers we implanted a total of 20 Zweymüller shafts and examined the femurs for ruptures of the shaft. Our special interest was the course of the fracture lines, their localization, and their display on roentgenograms. It appeared that fissures of the shaft are easily caused by the forced driving-in of the prosthesis. In about half of all cases the fissure cannot be seen on roentgenograms because of the site is covered by the implant itself. The fracture lines do not always begin intertrochanterally or from the calcar femoris; therefore, they cannot be recognized during surgery. This problem should be considered during implantation as well as during postoperative remobilization.